Case Study: Post-Surgical Rehabilitation of Bankart and Hill-Sachs Labral Lesions with a Ruptured Biceps Tendon.

By: Wade B. Price; ATS

INTRODUCTION Labral tears are an extremely common injury amongst athletes, especially athletes that participate in sports that involve extensive over-head arm motion. There are multiple types of labral tears that involve varying aspects of the glenohumeral joint. A Bankart lesion is a detachment of the capsuloligamentous complex from the glenoid rim, and it accounts for 87-100% of first time anterior shoulder dislocations.1 A Hill-Sachs lesion is an impression fracture of the posterolateral humeral head upon dislocation, and it accounts for 64-100% of first time anterior shoulder dislocations. 1 Most of these types of injuries present symptomatically with pain, possible clicking in the shoulder, weakness, and instability. According to the literature1 , combined lesions have become a more recognized and reported pathology. There is also a relationship between the location of the origin of the long head of the biceps and the types of labral injuries sustained.2 There are multiple forms of treatment for these varying labral injuries, many of them involving surgical procedures to repair the damaged labrum. The purpose of this report is to present the surgical treatment and rehabilitation process used in the case of a 21-year-old male wrestler, who had sustained both a Bankart and Hill-Sachs lesion along with a biceps tendon rupture, in comparison to what the most updated research suggests. See figure 1 below for a lateral view of a normal shoulder complex.
Phase of Rehabilitation Phase 1 Phase Specific Goals Allow soft tissue healing Decrease pain and inflammation Initiate protective range of motion (ROM) Prevent muscular atrophy Restore full pain-free ROM Increase dynamic stability and muscular strength Normalize arthrokinematics Improve strength, power, and endurance Enhance neuromuscular control Functional activities to prepare athlete for throwing motions

Phase 2

Phase 3

For exercises in phase three, the patient will continue to perform all stretches done previously including AROM exercises and passive stretching. Consistent with the literature we placed a great emphasis on getting the patients ROM completely reestablished, especially external rotation.12 Losses in external rotation ROM increases the occurrences of osteoarthritis, so all attempts to regain this motion should be made.12The physicians protocol also calls for neuromuscular control and dynamic stabilization drills. The loss of stability at the shoulder joint results in a lack of stimulation of the mechano-receptors at the shoulder.13 This in turn causes a lack of proprioceptive input to the central nervous center which can lead to abnormal muscle firing patterns and changes in joint stiffness.13 In addition to proprioceptive exercises, rehabilitation in phase three should involve strengthening for sports specific functions coupled with proprioceptive and kinesthetic exercises.14The physicians protocol was in line with this too. In addition, based on the physicians recommendations, the patient began more aggressive strengthening exercises such as the Throwers Ten program, isotonics, and progressive plyometrics. The patient also started an interval sports program to start to re-acclimate the patient back into sport.

Figure 2: Above is a table that covers all of the rehabilitation goals as written by the acting physician for this particular case. DISCUSSION Athletes that participate in sports that involve repetitive overhead motions have a predisposition for shoulder injuries because of the constant use in these extreme ranges of motion.5 In this particular case, as most wrestlers experience, the patient was put into an extreme overhead ROM which caused the patient to dislocate his right shoulder. The patient had a long history of anterior instability of his right shoulder. Anterior subluxations are often the source of overhead athletes problems such as limited range of motion or in severe cases labral pathologies.5 Even though there have been rehabilitation programs developed to treat anterior instability conservatively, operative intervention still may be required.5 It is also common for biceps brachii long head tendon injuries to occur in conjunction with tears of the glenoid labrum.4,6 In the case of our patient, he sustained a biceps tendon rupture in conjunction with his Bankart (the most common pathology from anterior shoulder instability)6 and Hill-Sachs lesions. He did require operative intervention in the form of a Bankart Repair. Post-operatively, during the first phase of rehabilitation (weeks 1-8) the patient was instructed to stay immobilized in a sling for the first 4 weeks as outlined in the literature.3 The patient completed exercises that focused on range of motion and stabilization. For the first 4 weeks, while still immobilized, the patient conducted isometric exercises in the sling for shoulder flexion, extension, abduction, internal rotation, and external rotation. Isometrics are extremely effective with strengthening the stabilizing muscles of the shoulder complex. 3,5 They also help the patient to regain neuromuscular control.3 The sling was discontinued after the first 4 weeks of the patients phase one program. The isometrics were still continued and more stabilizer muscle strengthening exercises were introduced. These exercises consisted of rhythmic stabilizations at 90 degrees of shoulder flexion, in abduction, and in scaption. These exercises, as recommended 5, were done with the patients hand pressed against an exercise ball which was pushed against a wall. Range of motion exercises were also introduced at this time. These exercises include assisted active range of motion (with the aid of a cane) for shoulder flexion to 90 degrees, abduction to 75 degrees, internal rotation(scapular plane) to 45 degrees, and external rotation(scapular plane) to 20 degrees. These exercises were limited to such small degrees, avoiding long arm lever motions for this stage of the rehabilitation process.5 The use of ice and electrical stimulation was continued throughout this phase, as instructed by the attending physician. The progression from phase one of this patients shoulder rehabilitation, post Bankart repair, to phase two was based upon the completion of his phase one program and exercises, as well as being cleared by the acting physician. As stated in the phase one analysis, this patient underwent a Bankart repair after suffering a labral tear while competing in the first wrestling match of the season. A typical Bankart repair has a standard healing time of about six months which is the approximate goal time span for this particular case.8 The phase two program for this patient was outlined by the physician to be within weeks 8-22. The primary goal for most all phase two programs is to try and return the patient to normal levels of flexibility and strength. As outlined by the physician, the phase two program was broken up into three progressive segments. The first segment is weeks 8-12, in which all exercises remained the same as phase one. All ROM exercises were progressed in degree. The second segment was weeks 12-16, in which all exercises remained the same and ROM was progressed further. The third segment was weeks 16-22, in which all exercises and ROM remained the same. In this final segment of phase two more aggressive techniques were cleared by the physician to start muscular strengthening. This phase two protocol differs from the literature as it does not yet involve whole body and core exercises. According to the literature, it is beneficial to include kinetic chain shoulder rehabilitation exercises to encourage flexibility and strength gains in more functional movements, along with improving neuromuscular function.7 Much of what has been outlined by the acting physician does, however, agree with the literature for phase two goals. As the research shows phase two is the time to become more aggressive in ROM and to increase the patients strength and neuromuscular function.9 The literature agrees with the physicians protocol on this matter including the means of achieving these goals through the use of isotonic dumbbell exercises.9 Another exercise that could be added in addition to the acting physicians phase two protocol would be a progressive series of Codmans pendulum exercises. Codmans exercises are a very beneficial method of distraction of the joint to allow an increased flow of nutrients into the joint space, as well as getting good motion out of the joint to help increase neuromuscular control.10 Overall, the physicians rehabilitation program for the patients phase two does agree quite well with the available literature. That being said, there are many other beneficial techniques that are not being utilized by this current program that could and possibly should be explored for this particular case. As the patient enters the third and final stage of rehabilitation, the focus turns more towards exercises to prepare the athlete for returning to competition. The goals for this patients phase three rehabilitation plan, according to the acting physicians protocol, are to improve muscular strength, power, and endurance, enhance neuromuscular control, and to start incorporating functional activities. Current literature completely agrees with the physicians goals for this phase as they too have their main phase three goals as improvement of strength, power, endurance, and neuromuscular control.11 In accordance with the physicians protocol, the patient could only enter into phase three after he has achieved full pain-free ROM, has no pain or tenderness, and has muscular strength at 80% of the contralateral side. This protocol varies very slightly from what is stated in literature. Research states that most post-surgical patients can enter into phase three once they have nearly full pain-free ROM and they must have 70% muscle strength compared to the contralateral side.11 The patient is currently still in his phase three protocol and doing very well with his rehabilitation. CONCLUSION Through the processes I have done to complete this case study including all of the research that went into this, I have learned a great deal about the complexities of designing a rehabilitation program for a post-operative shoulder as well as how to more efficiently create a basic rehabilitation program in general. To give my own recommendations as how to handle this situation, I would agree with most of this particular rehabilitation protocol. The physicians protocol almost entirely agreed with what I read throughout my research. It is within his phase two protocol that I differ from him. The research showed that integrating core and whole body exercises including closed kinetic chain shoulder exercises is a great way to start the strengthening process. I would also include Codmans exercises in my phase two. These exercises not only help with distraction of the joint encouraging nutrient flow, but they also help increase neuromuscular control through enhanced proprioception. I would leave all other exercises and protocols listed with this case study as stated.

REFERENCES IN AMA FORMAT: 1. Dickens J, Kilcoyne K, Giuliani J, Owens B. Circumferential Labral Tears Resulting From a Single Anterior Glenohumeral Instability Event: A Report of 3 Cases in Young Athletes. American Journal Of Sports Medicine [serial online]. January 2012;40(1):213-217. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed January 28, 2013. 2. Jakanani G, Botchu R, Rennie W. The MR arthrographic anatomy of the biceps labral insertion and its morphological significance with labral tears in patients with shoulder instability. European Journal Of Radiology [serial online]. November 2012;81(11):3390-3393. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed February 4, 2013. 3. Mcdonough A, Funk L. Critical reflection of the advanced rehabilitation of an elite rugby league player sustaining a posterior Bankart lesion. Phys Ther Sport. 2013;14(1):60-7. 4. Miller T, Jones G. Arthroscopic evaluation and treatment of biceps brachii long head tendon injuries: A survey of the MOON shoulder group. Int J Shoulder Surg. 2011;5(3):68-71. 5. Levine, W. N. (1999). New approaches to the care of the athlete's shoulder. Sports Medicine & Arthroscopy Review, 7(2), 128-133. 6. Jancosko JJ, Kazanjian JE. Shoulder injuries in the throwing athlete. Phys Sportsmed. 2012;40(1):84-90. 7. Mcmullen J, Uhl TL. A kinetic chain approach for shoulder rehabilitation. J Athl Train. 2000;35(3):329-37. 8. Miles JW, Tasto JP. Arthroscopic Bankart repair of anterior shoulder instability in the athlete. Operative Techniques in Sports Medicine. 2004;12(2):126-134. 9. Mccarty EC, Ritchie P, Gill HS, Mcfarland EG. Shoulder instability: return to play. Clin Sports Med. 2004;23(3):335-51, vii-viii. 10. Ellsworth AA, Mullaney M, Tyler TF, Mchugh M, Nicholas S. Electromyography of Selected Shoulder Musculature During Un-weighted and Weighted Pendulum Exercises. N Am J Sports Phys Ther. 2006;1(2):73-9. 11. Mccarty EC, Ritchie P, Gill HS, Mcfarland EG. Shoulder instability: return to play. Clin Sports Med. 2004;23(3):335-51, vii-viii. 12. Itoi E, Watanabe W, Yamada S, Shimizu T, Wakabayashi I. Range of motion after Bankart repair. Vertical compared with horizontal capsulotomy. Am J Sports Med. 2001;29(4):441-5. 13. Gibson J. (iii) Rehabilitation after shoulder instability surgery. Current Orthopaedics. 2004;18(3):197-209. 14. Stein T, Linke RD, Buckup J, et al. Shoulder sport-specific impairments after arthroscopic Bankart repair: a prospective longitudinal assessment. Am J Sports Med. 2011;39(11):2404-14. 15. Available at: http://www.therafit.com/Injuries-Conditions/Shoulder/Shoulder-Anatomy/a~361/article.html. Accessed April 23, 2013.

Figure 1: Above is a picture of the skeletal anatomy of a normal shoulder complex from a lateral view.15 This view gives a great depiction of the areas that were affected in this case, the labrum and the insertion of the long head of the biceps tendon.

BACKGROUND This patient is a 21-year-old male Indiana University wrestler. He presented with right shoulder anteroinferior instability. He participated in a wrestling match on the weekend of November 3rd, where he had two events where his right shoulder dislocated and had to be manually relocated. The wrestler said that he has had over 30 episodes of subluxation on his right shoulder previously. An MRI was ordered for his shoulder which showed a large Bankart detachment with a Hill-Sachs lesion. He had a positive anterior apprehension relocation test during his physical examination. This special test was the only performed. DIFFERENTIAL DIAGNOSIS For this particular case, possible injuries expected before proper evaluation were a SLAP tear, Bankart lesion, Hill-Sachs lesion, and a ruptured biceps tendon. TREATMENT After a physical examination with the physician, an MRI was ordered which revealed that the patient had a Bankart detachment with a Hill-Sachs lesion. It was also discovered that he had a biceps tendon rupture with disruption of the superior labrum. Upon discussion with the physician, the patient decided to proceed with the right shoulder arthroscopic Bankart repair. During the operation, the patients shoulder was examined again while he was under anesthesia. During examination the patient demonstrated 3+ anterior instability, and had no inferior or posterior instability. The surgeon performed an arthroscopic Bankart repair where a total of three anchors were placed into the anterio-inferior quadrant of the labrum. An arthroscopic superior labral repair was also performed at this time. Post-operatively, sterile dressings were applied, followed by a shoulder immobilizer. The patient tolerated the procedures well and had no complications. The surgery was performed on 11-8-12. On November 13, 2012 the patients sutures were removed and the physician cleared him to begin the first phase of his rehabilitation program. Since then, the patient has been advanced to the next phase of his rehabilitation program on 12-4-12. Specifics of the different phases for this patients rehabilitation will be discussed in the discussion section. For more information see figure 2 at top. UNIQUENESS Labral injuries among athletes are not uncommon by any means. This particular case, however, presented with unique characteristics as it involved more structures than the common labral pathology. The patient had a Bankart and Hill-Sachs lesion together which is rare but the most unique characteristic of this injury was that it also involved a complete rupture of the long-head biceps tendon.